Improving the safe use of time critical medicines

Jenna Murray
Hello, I’m Jenna Murray, Senior Specialist Pharmacy Technician in Medication Safety here at NHS Specialist Pharmacy Services [SPS]. In this episode, I’ll be talking with Ali Cracknell, Consultant in Acute and Elderly medicine; Philippa Duggan-Carter, Lead Nurse Parkinson’s Disease Specialist; and Jeremy Robson, Advanced Clinical Pharmacist for Neurology, from Leeds Teaching Hospital, NHS Trust, who have not only delivered a successful quality improvement project but have sustained it over several years.

In quality improvement, or QI, we know that one of the most challenging parts is sustainability. Many teams can deliver change, but fewer manage to embed it as business as usual. Whether you’re just starting a QI journey or thinking about how to make improvements stick, this conversation is about practical real-life lessons, honest reflection, and how this team made their changes last to improve patient care.

Hello, Ali, Philippa, and Jeremy.

Philippa Duggan-Carter
Hello

Jenna Murray
Lovely to have you here and thanks so much for agreeing to share your journey and insight with us. For our listeners today, could you provide a brief overview of your project?

Ali Cracknell
Thanks, Jenna, for the welcome. Well, the background to the Leeds’ quality improvement work around time critical medicine actually started ten years ago this year. And it started after a patient’s relative, Jane, wrote a letter, not a complaint, but just a letter to our Chief Medical Officer describing the experience her husband, Graham, had had in our Trust. He was a person with Parkinson’s disease, and he was an inpatient in Leeds hospitals for nine months and I think he was on between seven and eight different adult medical awards during that period. And to be honest, the letter for us was a very difficult read. The early part of his admission, there were virtually daily delays described by Jane in him receiving his Parkinson’s medication and just from reading the letter, having never met Graham, you could tell that this had massively contributed to a significant and rapid decline in his health and physical function because he came into our Trust independent, living at home with a condition unrelated to his Parkinson’s disease when he was admitted. And very sadly he left the Trust about nine months later physically very dependent and needing nursing home care. So that was when we needed to do something different just from reading Jane’s letter that she’d taken the time to write. And you can hear more from Jane in her video, she’s recorded a video about her story with Graham, her husband, and it’s called Graham’s Story told by Jane Throssell [see Lived Experience Input, above]. And that was the background to why we started the project.

I think at that time, Philippa and Jeremy, we also knew from audits and from people that were coming back to your clinics that Graham’s experience wasn’t unique, it wasn’t a one off, so we knew there was a lot of work to do, and that’s why we set up a Trust wide quality improvement project, which has been going ever since to be honest over a decade now, which is quite impressive. And if you want to read more about our journey in a lot of detail it has been published in the Journal of Age and Aging in 2020, and it’s entitled Get Parkinson’s Medication on Time, the Leeds’ Quality Improvement Project.

Jeremy and Philippa, do you remember that time ten years ago and how it felt to you with the patients you were looking after?

Philippa Duggan-Carter
Yes, I do and my nursing team was also, there was only two of us at the time, I now have five nurses, but we had tried to, you know, kind of, do teachings, it was a bit of an uphill battle. You know, we’d get patients in clinic who would say that they had quite a bad experience, not particularly from the nursing staff, but just medications; staff not understanding the need for multiple medication doses during the day, you know, patients having to ask for their medications or relatives having to prompt staff as well. And it was, it’s quite difficult trying to manage this because our Trust is very big, we have 92 wards. So, we had to, tried to initially audit this ourselves on paper charts as well prior to eMeds.

Jenna Murray
So, is this work that you tried to do previously before…

Philippa Duggan-Carter
Yeah.

Jenna Murray
…Graham’s story? Sorry.

Philippa Duggan-Carter
Yeah, so we, we’d got elderly medicine and acute admission wards on a different site to where we’re based, so, which is where the majority of our PD [Parkinson’s Disease] patients were based and would be admitted to. And unfortunately, what we used to see was patients being transferred across to the neurology wards, often because their medicines weren’t managed particularly well, which is what happened to Graham actually as well, he ended up coming to neurology and I remember Jane saying if they could do it on neurology, why couldn’t they do it everywhere else?

Jenna Murray
Yeah.

Philippa Duggan-Carter
Which was obviously a really good point.

Jenna Murray
Yeah.

Ali Cracknell
And you wouldn’t necessarily know would you at that time, Philippa, ten years ago that a person with Parkinson’s disease had actually been admitted to the other hospital, the other main hospital site at that time?

Philippa Duggan-Carter
No, we’d often be told by a patient’s relative either after the event or after they’ve been admitted, you know, a week prior to that. The online medical records was in its infancy across the hospital, so you wouldn’t always automatically know. We didn’t have any kind of alert system. We’d tried to ask IT in the past about having an alert system for when our patients were admitted and we were told we would have to go through every single patient’s notes to be able to put a flag on their notes when they came in. So, it was quite hard work in that sense, we were felt we were kind of being thwarted at every opportunity that we were trying to think about.

Jeremy Robson
Yeah and to echo it, obviously there was pockets of good practice, for example, within pharmacy we developed a specific time critical paper medication chart which was which was in use across the Trust, but again that’s in the days of paper charts. Like Philippa said there was pockets of audit, I got medicines and the person’s background, so there was always good practice and things, but again to keep, until you start doing a QI project, you don’t know what you don’t know. I think you’re trying your best, everybody’s trying their best until you widen that out and involve people, you’re not always expecting, it’s, that’s where it comes to fruition.

Philippa Duggan-Carter
Yeah, it became harder than, it felt it was harder than it should have been. You know, we’d tried to organise this training and the other nurse that I worked with at the time, Caroline, we would ring up the wards, try to speak to the person in charge, you know, said we’ll come next week and do some training and we’d turn up and they’d know nothing about it, or they’d say no we’re too busy, or they’d have one member of staff available, you know. And it was just, kind of, quite hard work and in between doing all our other job of…

Jenna Murray
Yeah.

Philippa Duggan-Carter
…you know, seeing patients in clinic, home visits, and stuff. So, we were kind of, it felt a lot harder than it should have been.

Jenna Murray
Definitely. So, how did you managed to get that wider team involved with the project then?

Ali Cracknell
Yeah, well I guess we knew right from the start that to reach across the whole Trust, as Philippa has said, we’ve got 92 adult wards, you can see why we weren’t making progress when it was a two person show trying to improve this. So we knew we had to get a multidisciplinary approach and what we actually did was set up a multidisciplinary QI collaborative, with a group of people to work with the frontline teams across all those areas, and to be honest, it wasn’t just wards; we wanted to reach pre assessment, we wanted to reach departments like radiology, and places like that. So, we brought a lot of professionals together. We actually involved Jane right from the outset, to bring the patient perspective and the engagement about why this is so important. We obviously had Philippa and a few of her colleagues, specialists Parkinson’s nurses as well as the Parkinson’s consultants, we had Jeremy in pharmacy, we had a physiotherapist, we had a speech and language therapist, a dietician, a radiographer. Probably a key person as well was the informatics specialist because you’ve already heard what Philippa said, we needed to know the patients were in the trust. We brought in some ward nurses and resident doctors as well, alongside quality improvement expertise from myself, and a colleague. And that group, that faculty really worked with frontline teams in different specialty areas, be it on a surgical ward like orthopaedics, or a gastroenterology ward, or an admissions ward for older people, also in the emergency department. We worked in all the different areas to really test and design different interventions to see what worked and if they worked in one specialty area, we would ask the next area to sort of test it and adapt it to their world a little bit. So, then we started to get learning across the whole organisation, if you like, about what could work and how we could get things better. So, the multidisciplinary approach was really, really crucial and I probably can’t underestimate the informatics person enough because, you know, to get the Parkinson specialists on board who’ve been, you know, banging their heads trying to sort this for years and years and only seeing disappointed staff and horrible stories from their patients, to get them on board, one of the first wins was to set up, sort of, an electronic alert that would pull out people who’ve been admitted with Parkinson’s, so we knew real time where they were within the Trust and we could start to in-reach and find out a lot more real time about what was going on for those patients.

Jenna Murray
Yeah, identification of our patients is so critical to us being able to, you know, be there and do what we need to, to make sure it’s all fine and right for them with the medicines.

Ali Cracknell
Yeah, I mean it’s no good finding out, you know, nine months later what a horrendous journey somebody’s had, or when they come back to clinic. So that’s why we wanted to get it right.

Jenna Murray
Yeah. And, Philippa and Jeremy, what made it feel different for you guys when, you know, the wider team became involved?

Jeremy Robson
So, I think probably the central theme is Jane’s story, I think, that’s the key to keep sharing Jane’s story to multiprofessionals. And the key thing for me was it’s not the clinical frontline people, it was also the porters and people like that that they were fully aware and involved in this and empowered because they would then ask the nursing staff or health carers whether it was ok to take the patient off for a scan, or whatever, so that’s the key. And obviously the IT. I’d obviously worked mainly in neurology at that time, but as I said I’ve got history in medicines for the older persons so, and pharmacy covers the whole site, so again, to work with different people and to use their skills, which obviously these people are always there but until you actually sit down around the table, and this was before Teams and everything like that, so there was a lot of physical meetings, there was still paper drug charts, there was a lot of burning shoe leather visiting wards, doing that. But everybody was enthusiastic to do it. Philippa, have you got anything else?

Philippa Duggan-Carter
Just, so, from our point of view as PD nurses it made our life a lot easier and we felt like we’d been, kind of, banging a drum to a very small audience. You know, now we had this real engagement, the Chief Exec at the time was very enthusiastic and he was very proactive and we got a lot of publicity across the Trust, newsletters, the Chief Medical Officer involved. So, when you’ve got from the top involved, it filters down which was great because it then was going out across all the departments so it wasn’t just neurology, then it was medicine for older people, then it became, you know, orthopaedics because we had patients coming in there, or then it was A and E who would be then giving their first doses and making sure that they were getting doses whilst they were still in the department. And it was interesting that, you know, we, kind of, were feeling, we’d be saying to patients, you must take the tablets on time, when we’re saying this in clinic and then we felt it was embarrassing that then they weren’t doing that in hospital, you know, so we were telling the patients to do it, but we weren’t doing it ourselves. So now that we were seeing that that was happening, you know, time critical meds were being written as time critical and there was a lot more awareness and people realised the importance of PD and medicines that it’s not just impacting the patient as well, it’s everybody else, you know, the staff as well.

Jenna Murray
Definitely. And did the team think about sustainability right from the very start of the project?

Ali Cracknell
Yeah, that’s a good question, Jenna. I mean when you get started on a project like this, it can seem quite overwhelming, can’t it? But I know from my background in quality improvement that to some extent you do have to think about sustainability right from the outset, if you want long lasting change. So for me here, our biggest driver to, you know, achieve timely administration of medication was to work on the culture change ‘cause if you can get that right, you’re much more likely to have embedded change long-term. That’s sort of half the battle. Because if one group of staff or key individuals move on, others still champion and educate the new staff about, you know, why it’s really important to do it and this is the way we do things around here. So if I take the example of for example, resident doctors, who rotate departments and into the Trust virtually every month of the year, it might be the role of the ward nurse, the pharmacist or the consultant to really role model when someone hasn’t been able to take a dose of Parkinson’s medicine that we immediately come up with plan B to sort that and that’s what we do round here. And that’s sort of, it’s become everybody’s business, whoever you are, you will say to the one new person who may not been aware of all the work or the history of what’s happened, why we do it like that and why we don’t just omit a medication and wait for the next dose anymore, we will take action and there’s a lot of policies, protocols and people to help you out there who will tell you exactly what to do within minutes.

Jenna Murray
Sounds really good. It sounds like the staff are really empowered as well to be able to have them conversations with fellow colleagues who may be new and things like that. Really, really good to hear.

So, I know from previous conversations that there was a new EPMA [Electronic Prescribing and Medicines Administration] system implemented while you guys were on this journey. How were you able to navigate that at what must have been quite a challenging time and something that was quite significant for your Trust to go through at that time?

Jeremy Robson
Yes, it definitely was and we forget sometimes that we’re still using all these paper charts and things until we start preparing for something like this, what we were still doing it in 2016. So, yeah, our eMeds electronic prescribing system came into fruition around 2017/2018. Obviously as a big trust, it wasn’t started everywhere at once, so a massive challenge, but from a time critical point of view, it was a perfect timing. We’d been working on cultural behaviour change, so engagement and momentum to embrace the additional benefits of the eMeds system could bring. For example, we can monitor data, we can set time critical medicines for time critical for, our standard was 30 min, so it would alert the nursing staff. So alongside the education we were also able to build protocols for patients who weren’t able to do, to take oral medicines, so medicines down in the enteral tube or so with swallowing problems, and also with, in emergencies if the patient couldn’t swallow things like, there’s the Rotigotine patch, so we built protocols to be able to, so the staff could apply that out of hours.

Philippa Duggan-Carter
Just, from my point of view as a nurse, you know, I’m based at the LGI [Leeds General Infirmary] and if a patient is at one of our other sites, so for St. James’, on one of the older people’s wards or acute admission wards, I could just log on remotely and say, oh yeah, all the meds are written up correctly, getting them on time and obviously with the eMeds they have to, if there’s a dose been missed for whatever reason, they have to document why. So you can say oh patient’s in scanning or, you know, they will def-, put a reason on or dose unavailable or something, so you know the reason and then you can look on the notes and it’ll say ‘medicine’s ordered’ or ‘patient not able to take medication but actually off the ward sent down to scan with their tablets’, or something like that. So, you knew the culture was changing. So certainly from our point of view, it was good because we knew, we could remotely see what was happening without having to get on a shuttle bus and go across Leeds to physically go to a ward and see what was happening.

Jeremy Robson
And you could also, you could also tell who’d given a medication, who prescribed a medication, from a pharmacy point of view, who validate the medications so if there’s anything that needs to be improved you could target individual staff as well.

Ali Cracknell
I think it came at the right time, didn’t it eMeds for us. Had we started with eMeds, I don’t think we would have got far quickly in terms of time critical medication, but because we’d already done a year or so of the engagement, the importance, the culture work behind the scenes, people saw it actually as an added benefit; by going to eMeds this was going to help us get further quicker and, really help us with the data side because again that was key to knowing we were making a difference, driving further improvements because we were collecting data on, you know, process and outcome measures, and actually as Philippa and Jeremy said, as soon as we could remotely collect the data from electronic meds charts, that was so much easier than going to find, you know, a time scribbled on a paper chart.

Jenna Murray
Sounds like you guys really, sort of, you know, used what could have been a scary time for a lot of people working at the Trust, you know, to your advantage and all of that culture work that you’d done leading up to it, you know, is obviously really benefited that and people have embraced, you know, the electronic prescribing system which has clearly added to the improvement program too.

Ali Cracknell
Yeah, the other thing to say is sometimes when you’re doing quality improvement work, there’s a lot of things outside your control that you, you know, you can feel are going to be a car crash and mess with the work you’re doing. So, I could have seen eMeds as being like an absolute disaster coming in the middle of trying to improve 92 wards’ time critical medication, but you have to see that as out of your control, what are the benefits of it coming and work, I guess our work was quite widely publicised, as Philippa said, so we, the Parkinson’s and time critical meds was part of the initial build of the eMeds system. So, you know it was a win-win if you like, we could get what we wanted and needed straight away because it was seen as priority. So that made a difference, didn’t it?

Philippa Duggan-Carter
It did and I think that was, like going back to one of the earlier points about the whole wider team being involved, until you get a quality improvement project, you know, you would never have thought to include the IT team as well, where actually they were crucial to this with eMeds as well and you don’t realise who you need to involve until you get somebody from outside, like the quality improvement team, looking at it for you. You just think it’s just about going to a ward when actually it is a lot more of a collaborative and it was all the better for it.

Jeremy Robson
And also, the discharge prescription was on eMeds, eMeds electronic patient records, so that was sent to the GP as well so the primary care could see exactly what was done and also in, retrospectively we could see what had been prescribed on a discharge letter on whatever ward. So again, we could tie up loops and things like that if we needed to.

Jenna Murray
How did you know that this work became part of business as usual in your Trust?

Ali Cracknell
Well for me, when I realised it was business as usual was when we went through the COVID pandemic because obviously that was a massive, massive challenge and we couldn’t go and visit our wards as much as we wanted to. A lot of the reviews from specialist teams were remote, but we built in our, sort of, data measurement system of, you know, how many time critical meds had been omitted, what was the percentage of meds given within 30 min of when they were due. So, we were continuing to monitor all that data through COVID, and if you like, the actual QI approach, all our input was much more light touch, but the data did not change, the data had maintained those improvements. So that’s when I was like, whoa, this is, again COVID is a scary time, and you just think things are going to go downhill massively. But actually, when the teams were so focused on trying to manage a pandemic, yet the patients were still getting their time critical meds on time with no deterioration in the metrics, that’s when I knew that this was business as usual. But you can’t totally sit back, can you, because, you know, things change, you have to keep monitoring things, and you have to react to any signals that things maybe slipping in one area perhaps and then it’s not as hard to get going again ‘cause you know what’s worked, you’ve just got to go, visit, nudge, find out what’s going on, provide some more materials, the tools, the techniques, education, etc., and to get back to where you were. I don’t know, would you agree, Philippa and Jeremy?

Philippa Duggan-Carter
Yeah, I would. I mean prior to the quality improvement project, I used to do two award rounds a week, which was half a day each because we used to have so many PD patients on the neurology ward and they were invariably transfers across from acute admission medicines, because they’d have lots of delays in their medicines their PD had deteriorated, you know, missed medicines, you know, there were increased falls, all these kinds of awful complications. And interestingly after we’ve done the QI project, one of the sisters on the neurology ward had been on maternity leave and she came back and commented how few patients were being transferred over, so we used to always have six or seven patients on neurology with PD. She came back from maternity and said yay, we’re not getting any patients over, are we? And we all looked at each of them went oh yeah that’s right, yeah, we’re not anymore. And it had taken somebody else who had been off to come back and, kind of, point that out to us. We’d just taken it for granted then it was all working well and not getting the transfers across. So now we only tend to get elective admissions for PD, not these transfers of, you know, kind of, poorly managed patients.

Ali Cracknell
Because we can trust and know that they’re having their time critical medication whilst they’re being managed often for other illnesses across the organisation.

Jenna Murray
What an amazing observation by that nurse who came back from maternity leave.

Philippa Duggan-Carter
Yeah. I know I always remember her saying it. And there’s also the momentum that we see just anecdotally of, you know, when I know that patients are in, I routinely see time critical meds, you know, administered in part of, just the clinical notes from the nurses. You know, I see that, you know, all the time and I checked drug charts, you know, patient’s relatives will ring me up and say oh my husband’s in so and so and I instantly go into their drug chart and I just don’t see delayed medicines or missed medicines anymore. So, it’s great that obviously the message has got through when it’s still being seen as now it’s important and people know why.

Jenna Murray
What are your top tips for engaging staff long-term?

Ali Cracknell
Shall I start on that one? I’ve got probably two top tips. One is have your eye on the data and remember that between every data point, each number is a patient. So, my second point really would be around using patient stories, so some people like the hard data, the analytical side, but stories bring the emotion of why this is important to get right. You know, you, any of our wards could have a person with Parkinson’s disease on and this is why it’s important because it makes a massive difference to people when they’re an inpatient. So, they’re my two top tips.

Jeremy Robson
Yeah, it’s talking to staff, making the effort to talk to people and obviously learn by your actions as well, so that that’s important. Obviously again with involving patients as well to then, staff can see that patients are self-medicating or involved in their care as best as we can do on acute wards and then patients can learn. Obviously, it’s challenging with new staff continually going through and locum staff and agency staff, so it is a challenge all the time. Do you have anything to add Phillipa?

Philippa Duggan-Carter
I mean one of the things that we built on then was we used to, kind of, we’d go over once or twice a week to the acute hospital wards over at St. James’, but part of the quality improvement, we recognised the need for a regular consultant review on the acute wards over at St James’, so we’ve established a proper referral pathway for LGI and St James’, which is medical led as well. So, their movement disorder specialists, so some of those patients are under those consultants or they’re based on the frailty and older people’s wards. We’ve got lots of information that’s available on the internet and intranet, staff intranet, so things like guidelines, we’ve, we’re updating those. We’ve written another emergency medicines guideline, so from our experience, we’ve said right if a patient comes in as emergency, this is what you need to do with their medicines. If they’re on a pump infusion, here’s the information how to set that pump up, all the available set up, who to contact, and so patient work well without an infusion just because they’ve been admitted at 2 o’clock on a Saturday night, you know, so that information is there. It’s, staff know where to contact, who to contact, what, where, what’s available where. So, it’s just kind of spreading it across, you know, all the information of where people know that they can get help and if, you know, so a patient doesn’t suffer in their admission because nobody knows where to get any advice.

Jenna Murray
No, that, like, access of information to support our staff and our wider teams is so important.

How did you keep the staff motivated after the initial excitement of the project ceased?

Ali Cracknell
Well, I guess for me it was around positive feedback and celebrating achievements. So, as we could see the data improving, we would give certificates of improvement to the wards, the senior leaders in the organisation would help deliver those. So, sort of, keep driving the positive story about why this is important and celebrating when things go well rather than looking at the rare times when things go badly, we wanted to flip the coin really and make sure we keep the positive feedback going. And I think for us the positive motivation was around the sense that we never wanted another patient to have an experience like Jane and Graham did in our Trust and we never wanted Philippa and Jeremy to hear the stories of patients after they’ve been admitted and discharged telling them what had happened. So it was that sort of motivation to know real time if there was a problem and intercept it quickly, so the outcomes were not impacted like they had been for Graham. That was my motivation, and I think for a lot of the team, I don’t know if yours is different Philippa?

Philippa Duggan-Carter
I get, still get contacted about teachings as well. So, you know, I get contacted by the community. We’ve got training sessions that we’ve sent out across the Trust as well. I’ve been asked to do teachings, I teach at Leeds University as well for student nurses with, I do teach across the Trust, so people do contact me which I feel is good that, you know, people will still want to know, they want to learn and, you know, they may have had an experience with a patient that, who’s had Parkinson’s but they don’t have that experience for a long time, they might not have had a patient with Parkinson’s on their ward, so, you know, they’ve identified learning needs and they’ve contacted us so we can, you know, we’re always available and, you know, we just think if people want to learn and, you know, they’re happy to ask us, we’ll go and help out.

Ali Cracknell
Can never stop improving, can you.

Philippa Duggan-Carter
Exactly.

Jeremy Robson
We were very lucky with obviously we’re a great story but we’re lucky that that Jane was so passionate to help improve. She used to attend, she was committed, she used to attend regular meetings and that was a big motivation to keep staff engaged and continue to improve care, she, yeah, she was always wanting to be involved.

Jenna Murray
Ali, Philippa and Jeremy, thank you so much for sharing your experience and insights with us today. I am certain that this will not only inspire our listeners but will help them to embed lasting change and improve patient care in their organisations.